Conducting an Exposure Assessment Evaluation Issues

Conducting an Exposure Assessment Evaluation Issues Relevant to the Military and Veteran Population

Omowunmi (‘Wunmi) Osinubi, MD, MSc, MBA, FRCA, ABIHM Occupational & Environmental Health Physician War Related Illness and Injury Study Center

August 2013

VETERANS HEALTH ADMINISTRATION

Purpose of Exposure Evaluation

• Better understanding of Veteran’s exposure concerns

• Evaluate relationship between exposures and health conditions

• Opportunity for patient education

• Inform diagnostic assessment

1


Occupational and Environmental Exposures in the Context of Military Service

What does it mean to be a Veteran?

ASK ▪ LISTEN ▪ LEARN 2


Cultural Competency

What is the military?

• “Not just a job, a way of life.”

• Duty ▪ Honor ▪ Courage

• Service to Country

• A Vet is a Vet

• History and Purpose

• Organizations:

– Army

– Marine Corps

– Air Force

– Navy

– Coast Guard

3

Military Structure

SERVICE ARMY AIR FORCE NAVY MARINE CORPS

COAST GUARD

ACTIVE DUTY 539,675 372,620 368,217 177,021 39,006

NATIONAL GUARD 360,351 108,488 N/A N/A N/A

RESERVE 197,024 75,322 82,558 39,644 8,500

TOTALS 1,097,050 556,430 450,775 216,665 47,506

4 VETERANS HEALTH ADMINISTRATION


Differences Between the Conflicts: Stressors

• Volunteer vs. Draft

• Lengthy or Multiple Deployments

• Technology

• Civilian Support

• Threats

• Media

• Casualties

5


Today’s Military Demographics in Comparison to the Draft Population

• Average age is older

• Educational backgrounds – higher percent college graduates,

high school/GED requirement

• Marital status (percent married higher)

• Heritage: Family history of military service that may span

multiple generations

6


Environmental Exposure Assessment Step by Step “How To”

• Introduction: Display empathy and care for the Veteran to

establish trust and credibility. Tell the Veteran upfront that you

will be honest - explaining what you do and don't know. Listen

actively and patiently.

• Explanation of plan: Describe how you'll conduct the

assessment to give the Veteran some "control" and make them

a partner in the assessment. Think about the fact that this is a

Veteran who is trained to listen to authority but may feel like

they have had that trust violated.

• Basic toxicology: Explain the need for a route of exposure and

for a temporal relationship between exposure and effect.

Explaining this in the generic sense may make discussions of

specific exposures much easier for the Veteran to understand.

7


Environmental Exposure Assessment Step by Step “How To” (cont’d.)

• Exposure history pre-enlistment/pre-deployment: Ask about location of birth,

residencies, environment, schooling, neighborhood exposures, hobbies, travel,

summer activities, and all jobs, etc.

• Exposure history during deployment: (Stay tuned)

• Exposure history post-deployment: Same issues as in pre-deployment exposure

history. Ask about multiple deployments. Include treatments for conditions which

began post-deployment.

• Exposure history post-separation: Again ask about residencies, hobbies, travel,

employment, etc. Many Veterans become government contractors with the same

types of exposures as when they were active duty.

8


Environmental Exposure Assessment Specific Concerns Related to Deployment

• This is what the Veteran came to talk about.

– Time, duration and location of deployment(s)

• In area of hostilities? (Under fire and/or fired weapon)

– Chemical weapons/alarms? (use of MOPP gear/gas mask – for how long?)

– Prophylactic medicines? (anti-malarials, nerve agent antidotes)

– Biological weapons

– Sanitation during deployment? (illness while in theater)

– Chemical exposures? (solvents/petrochemicals/pesticides/herbicides, etc.)

– Exposures to body fluids/dead bodies? (mass graves, etc.)

– Exposure to air pollution – general or a specific factory, e.g., cement/asbestos dust?;

burn pits smoke? sand/dust storms?

– Insects/arthropods/bugs, including flies?

9


I was exposed to DU

radiation, oil well fires,

sand/dust storms; there were

nerve gas alarms; I took

nerve pills, got the anthrax

shots and other unknown

hazards ……I think I have Gulf

War Illness.

Environmental Exposure Assessment Case #1: 55year old Gulf War Army Veteran (GW)

• What exposures are the

specific exposures that

the Veteran is concerned

about?

– Prioritize and rank

exposures of concern

• Address each specific

exposure related to his

deployment/military

service

• Ask about “other

exposures”

– Veteran is a partner in

the process

10


Addressing Specific Exposures of Concern: How to Elicit, Assess, and Find Information

11

Exposure Assessment Important Elements

Who Where When How What Why


Who?

• Who was exposed?

– Vietnam Veteran and Agent Orange exposure Boots on the ground in Vietnam

• Did others have similar exposures and outcomes?

Korean demilitarized zone

Thailand military bases

Brown Water Veterans

• Any pre-existing conditions/exposures that would place the exposed at greater risk

of disease development?

– Yes, he had exposures to solvents possibly contaminated with benzene

• Increased risk for leukemia with/or without Agent Orange exposure

12


When and Where Did the Exposure Occur?

Korea 1950 -1955

Vietnam 1961-1975

Gulf War 1990 -1991

Somalia 1992 -1993

Bosnia 1995-1999

OEF 2001 -

present

OIF 2003 -2010

OND 2010 – 2011*

13

Exposures by Conflict

“On December 15, 2011, U.S Armed Forces in Baghdad marked the official end of the war in Iraq.” From: Torreon BS. US Periods of War and Dates of Current Conflicts. Congressional Research Service 28 December 2012.


How did the Exposure Occur? Factors Relevant to Assessing Exposures

Inhalational exposure

•Airborne harmful substances

•Aerosols and vapors

•Dust

Oral exposure •Foodstuffs

•Drinking water

•Soil and dust

•Prophylactic meds

Dermal exposure •Radiation

•Solvents

•Personal pesticides

•Injection

•Penetration

Image from: http://www.umweltbundesamt.de/gesundheit-e/bilder/Expositionspfade.png

• Routes of Exposure – Inhalation > Dermal > Oral

• Types of Exposures – Unique to deployment, MOS, Military

Conflict

• Any Means of Protection – Application and Use

• Ease of Use

• Training

• Climate

• MOS

• Potential Health Effects – New disease processes

– Impact on pre-existing condition

– Disorders that can be remedied versus those that cannot

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http://www.umweltbundesamt.de/gesundheit-e/bilder/Expositionspfade.png

What Was the Exposure? Case Study #2: OEF/OIF Veteran

• What is respirable dust and was our OEF/OIF Veteran exposed?

• What sizes should be of concern when considering the upper airways, lower airways?

15

I’m in limbo….My breathing problems

are changing my life…I don’t understand

what’s going on……I’m going through a

tough time….But that doesn’t mean that

I’m crazy.


Pathophysiology of Airborne Inhalational Hazards

• Particles between 0.5 and 1.0

µm are likely to be deposited

and retained in the alveoli

VETERANS HEALTH ADMINISTRATION 16


OEF/OIF Vet Case #2: Deployment-Related Exposures Inhaled Particulates Penetrate Deep into the Lungs Causing Symptoms/Disease

Asbestos

(≤ 0.2μm in diameter and > 5μm in length)

Concrete dust

(alkaline - penetrates deeper in lungs)

Cement dust

(0.05μm- 5.0μm)

Combustion-by-products

*Sand/dust storms

(200 -2000 μm)

*≤ 3μm

Jet – engine exhaust and noise

Excessive weight bearing

No combat exposures

17


Why Did Exposure Occur? Rationale for Military Vaccinations

• Important for military force health

protection in peacetime and in war

• Protect troops from:

– Infectious diseases that are common

to US populations

– Serious/deadly infectious diseases in

deployment situations

– Biological warfare agents

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Vaccines Routinely Administered to All Military Recruits (GW Era)

Vaccine Schedule

Adenovirus 1 oral dose

Influenza Annual shot

Measles 1 shot

Meningococcal 1st shot and booster every 3-5 years

Polio 1 oral dose

Tetanus-Diptheria Booster every 10 years

Rubella I shot

Small pox (through the late 1980s)

1 dose

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Vaccines Administered to Special Military Occupations (GW Era)

Vaccine Personnel Schedule

Plague Marines, Navy, Army, Special

forces, at-risk occupations or

deployment to at risk areas

5 shots over 12 months

then booster every 1-2

years

Smallpox Vaccine or booster to new

recruits through the late 1980s

1 dose

Typhoid Army and Air Force alert forces for

deployment to high risk areas

2 doses in 2 months, then

booster every 3 years

Yellow Fever Navy, Marines, Army and Air

Force alert forces and for

deployment to high risk areas

1st shot, then booster

every 10 years

20


Risk of Dying

21

Smoking 10 cigarettes a day One in 200

Road accident One in 8,000

Playing soccer One in 25,000

Homicide One in 100,000

Terrorism attack in 2001 One in 100,000

Hit by lightning One in 10, 000,000

Terrorism attack in 1990s One in 50,000,000

Anthrax in 2001 One in 50,000,000

Smallpox in 2001 Less than One in 50,000,000


Biological Weapons (BWs)

• Biological warfare

– Dispersal of biological agents including microbes and/or their

toxins to cause widespread illness, death and/or terror.

• Characteristics of BWs

– Low visibility and high potency

– Substantial accessibility and easy delivery

• Since 1980s terrorist organizations have become users of biological

agents

• Iraq began an offensive BWs program in 1985

– After the Persian Gulf War, Iraq disclosed that it had bombs, Scud

missiles, 122-mm rockets, and artillery shells armed with

botulinum toxin, anthrax and aflatoxin.

– Spray tanks fitted aircrafts that could distribute 2000 L of BWs

over a target

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Anthrax

• Zoonotic acute infectious disease

– Bacillus anthracis spores viable in thesoil for decades

– Incidence - one case/year in the US

• Cutaneous anthrax - 95% of all cases of anthrax

– Small papule, then ulcer with blackeschar, heals in 2-3 weeks, septicemia is rare, mortality rate is 1%.

• Gastrointestinal anthrax

– Ingestion of infected meat

– Nausea, vomiting and diarrhea, fever,tonsilar enlargement, acute abdomen,massive ascites, mortality rate 50%

• Meningitis

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Pulmonary Anthrax -“Woolsorter’s Disease”

– Inhalational anthrax is the most likely form of disease to

follow military or terrorist attack

• Such an attack likely will involve aerosolized delivery of

anthrax spores

– Fever, malaise, fatigue, myalgia, respiratory distress which

may be followed by onset of shock and death within 24-36

hours

– Mortality rate is 80-90%, but may approach 100% if septic

shock

– Of the 11 cases of inhalational anthrax in the 2001

bioterrorism attacks in the US, only 6 patients survived (65%

survival rate)

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Smallpox (Variola)

• Most notorious of the poxviruses

– Responsible for the death of more

people than any other acute infectious

disease

– 1977 - last known case was in Somalia

– 1980 - endemic small pox eradicated

(WHO)

• Highly infectious, environmentally stable,

retains infectivity and significant BW threat

• Systemic viral disease

– Skin lesions, high fever, headache,

myalgia, vomiting, abdominal and back

pain

– Case fatality rate:

• 30% in unvaccinated

• 3% in vaccinated persons

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Botulinum Toxin (BTs)

• Most lethal toxin known

– Toxicity is 10,000 – 100,000 times greater than

chemical nerve agents

– 1 gm crystalline BT can kill > 1 million people if

dispersed and inhaled evenly

– Point source aerosol release can incapacitate/kill

10% of people 0.3 miles downwind

• Credible threat as BW agent

– Extreme potency and lethality, ease of production

and transportation, need for prolonged intensive

care of survivors

• PGW - Iraq weaponized 19,000L and deployed more

than 100 munitions with BT

Clostridium botulinum

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Clinical Features of Botulism

• BT prevents release of acetylcholine at the pre-

synaptic neuromuscular junction and cholinergic

autonomic sites

• Classic Triad

– Flaccid paralysis with bulbar palsies

• Diplopia, dysarthria, dysphonia, dysphagia (4 D’s)

– Afebrile

– Clear sensorium

• Most serious complication is respiratory failure

– Mortality <5% with supportive care

– Recovery requires months for the neurons to

develop new axons

JAMA. 2001;285:1059-1070

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Mandatory Bio-warfare Military Vaccines: So Why Did the Exposure Occur?

28


Risk of Dying

Smoking 10 cigarettes a day One in 200

Road accident One in 8,000

Playing soccer One in 25,000

Homicide One in 100,000

Terrorism attack in 2001 One in 100,000

Hit by lightning One in 10, 000,000

Terrorism attack in 1990s One in 50,000,000

Anthrax in 2001 One in 50,000,000

Smallpox in 2001 Less than One in 50,000,000

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Vaccination Adverse Effects

• No immunization is completely safe

• Some Servicemembers who received these vaccines have developed medical

conditions which they are attributing to vaccines

– Migraines, heart problems, diabetes

– Multiple sclerosis, neuropathies, medically unexplained gastrointestinal, neuromuscular

and musculoskeletal problems

• Questions have been raised about effects of receiving multiple vaccinations over a

short period of time versus reaction to any single vaccine

• Case reports of similar health problems in soldiers who received the vaccines but

did not actually deploy

30


Smallpox Vaccine

• Vaccination is safe and effective for most people

– Mild symptoms

• Local soreness and redness

• Enlarged regional lymph nodes

• Low fever

– 1 out of 3 people may feel unwell enough to miss work

• Serious reactions

– Vaccinia rash - localized or widespread (generalized vaccinia)

– Toxic allergic rash to the vaccine (erythema multiforme)

– 1 in 1000 recipients

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Smallpox Vaccine (cont’d.)

• Life-threatening reactions

– Eczema vaccinatum

• Widespread severe skin infection in persons with eczema or atopic dermatitis

– Vaccinia necrosum

• Extensive tissue destruction leading to death

– Post-vaccinal encephalitis

• More recent developments

– Causal association between vaccination and myocarditis

– Angina and heart attack have been reported post-vaccination

– Persons with post-vaccination chest pain, shortness of breath or cardiac disease must

seek medical attention ASAP

32


Anthrax Vaccine (Gulf War)

• AVA was licensed in 1970

– Alumnium hydroxide-adsorbed preparation

• Vaccination series comprised 6 subcutaneous injections over 18 months

– 0, 2 and 4 weeks; 6, 12 and 18 months; annual boosters

• There was not enough time or adequate AVA supplies to vaccinate all the troops in

time for deployment

– 41% of all US vets; 30% of Navy Seabees reported receiving AVA

33


AVA – Public Perception

• Media controversy and public debate fueled by several factors

– ? Efficacy against inhalational anthrax

– ? Manufacturing quality control problems

– ? Short and long-term side effects

– ? Vaccine components and adjuvants

• “Squalene” vs Aluminium hydroxide hypotheses

– ? Military policies that first mandated vaccinations, punished refusals for vaccinations

and later retracted mandatory vaccination

– ? Indications for vaccinations was not uniformly applied

– ? Vaccinations performed in “secrecy”, inadequate informed consent, and incomplete

documentation of anthrax vaccinations

– ? Variability in vaccines used

• Differences in vaccines used prior to the 1970s versus Gulf war vaccines

• Differences in US versus UK military vaccines

• Differences in reactions/adverse effects associated with different lots of the AVAs

34

With Permission -http://www.johnlund.com/page.asp?ID=2154

35

http://www.johnlund.com/page.asp?ID=2154


Questions About Military Vaccinations?

• Vaccine HealthCare Centers Network

– Walter Reed Regional Vaccine Healthcare Center (Bethesda/Ft. Belvoir).

– Fort Bragg Regional Vaccine Healthcare Center, NC

– Wilford Hall Regional Vaccine Healthcare Center, Lackland AFB, TX

– Naval Medical Center Portsmouth Richard E. Shope Regional Vaccine Healthcare Center, Portsmouth, VA

• DoD Vaccine Clinical Call Center 24/7 at:

– 1-866-210-6469

– VHC Physicians with expertise in vaccinology are on-call to assist the nurses in answering patient and provider inquiries.

– http://www.vhcinfo.org

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http://www.vhcinfo.org


Other Exposures of Concern? Pesticides and Gulf War

• “On a nightly basis, we would spray our uniforms with

pesticides…. We had to hang them outside so that the excess

spray would dissipate in the air….

…The sand fleas were a problem. We used to put flea collars

around the legs of our cots, or we would put flea powder on

the floor around our cots to try to keep the sand fleas away

from us while we were sleeping…

…We slept with nets over us to keep the flies off….The flies

were ungodly” – --SSgt TS, Gulf War Veteran (GRAC Report, 2008)

37


Pesticides: Classification by Use

Chemicals designed to kill, reduce, or repel pests

Insects

Insecticides

Weeds

Herbicides

Insect repellants

Molds

Fungicides

Rats, mice, moles

Rodenticides

Wood preservatives

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Fumigants


Pesticides: Classification by Use and Chemical Structure

• Different chemicals used for different purposes

INSECTICIDES

• Pyrethroids

• Organophosphorus

• Carbamates

• Organochlorine

• Manganese compounds

FUNGICIDES

• Thiocarbamates

• Dithiocarbamates

• Cupric salts

• Tiabendazoles

• Triazoles

• Dicarboximides

• Dinitrophenoles

• Organotin compounds

• Miscellaneous

RODENTICIDES

• Warfarines

• Indanodiones

HERBICIDES

• Bipyridyls

• Chlorophenoxy

• Glyphosate

• Acetanilides

• Triazines

INSECT REPELLENTS

• Diethyltoluamide (DEET)

FUMIGANTS

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• Aluminium and zinc

phosphide

• Methyl bromide

• Ethylene dibromide


Mechanism of Action: Organophosphates and Carbamates

• Inhibit the enzyme, acetylcholinesterase

(AChE) which normally functions to

degrade acetylcholine in nerve synapses

– Build up of acetylcholine (ACh)

– Overstimulation of ACh receptors

• Effects of multiple exposures are additive

(flea collar, insect repellant, home and

lawn treatment)

• Effects can be long-lasting

40

Highly toxic to animals, pets, livestock and humans


Acetylcholinesterase Inhibition

41


Acute Effects of Cholinesterase Inhibition (Nerve Agents)

42

Muscarinic Nicotinic Diarrhea

Urination

Miosis**

Bradycardia

Bronchorrhea

Bronchospasm

Emesis

Lacrimation

Salivation

Lacrimation

Urination

Defecation

GI symptoms

Emesis

•Tachycardia

•Hypertension

•Mydriasis

•Neuromuscular junction** •Fasciculation

•Weakness

•Paralysis

** Most important effects after exposure to

nerve agent(s)

•CNS •Anxiety, confusion, ataxia, dysarthria

•Seizures**

•Respiratory depression**

•Coma


Chronic Health Effects of Cholinesterase Inhibitors

• Organophosphate-induced delayed polyneuropathy (OPIDN)

– Occurs 2-3 weeks after exposure to large doses of OPs

– Due to inhibition of neuropathy target esterase

– Distal muscle weakness with relative sparing of the neck muscles, cranial nerves, and

proximal muscle groups

– Pathology shows dying back neuropathy of distal peripheral nerves

– Recovery can take up to 12 months

• Long term (years) work exposures (dippers/sprayers)

– Deficits in cognitive/neurobehavioral tests (memory, abstraction, sustained attention

and/or speed of information processing)

– Decreased vibrotactile sensitivity

– Normal EMGs/NCVs and neurological examination

43


Use of Pesticides in 1st Gulf War: At Least 64 Pesticides/Related Products

• Large numbers of flying and biting insects and other pests

– Environmental fogging and spraying

• Pest control important part of force protection and readiness

• Military issued pesticide creams, liquids, sprays for skin, uniforms and beddings

– Personal repellants – 33% cream or 75% liquid DEET on the skin,

– 0.5% Permathrin sprayed on uniforms

– Troops self-acquired pesticides – flea collars, citronella products, OFF, etc.

• Pest strips, baits and sprays used in living quarters

• Lindane (organochlorine) used for delousing in processing > 87,000

enemy/prisoners, distributed to US Army personnel for their use

44


Personal Repellants

• DEET (N,N-Diethyl-3-methylbenzamide)

– Developed by the US Army after WW II

• Originally tested as a pesticide on farm fields

• Entered military use in 1946, civilian use in 1957

– Protects against mosquito and tick bites

• True repellant- mosquitoes intensely dislike odor

– Prevents Lyme dx, malaria, dengue fever, etc.

– Inhibits acetylcholinesterase and potentiates carbamates

– Excessive DEET and/or concurrent pesticide exposures

• Insomnia, mood disturbance, impaired cognitive function

45


GW Pesticide Overexposures

• Pesticide overuse was common and at times extreme, particularly among ground

troops

– 62% used some form of pesticides

– 50% used DEET a median of 30X/month

– Permathrin used on uniform average almost 30X/month

• Label states spray on uniform once every 6 weeks

– 13% used pesticide sprays 50X/month

– 5% used pesticides >100X/month (>3X/day)

46

47

“It also seems reasonable that people in

environments with large numbers of insects

such as the Persian Gulf, would be tempted to

use whatever means was available to remove

pests, including using products in ways that

were not recommended.”

-RAND National Defense Research Institute, Pesticide Use During the Gulf War


Gulf War and Chemical Weapons

• “My unit arrived in the Gulf the day before the air war started. We spent about 1

month in Saudi Arabia. Our chemical alarms went off several times during that

month…we had to go to MOPP – level four...

…While in Saudi Arabia, we started taking PB pills…about 3 days after, my eyes

were jittery, my vision was jumping, I was seeing double, and I was

nauseated…

….By the 4th day, I was vomiting a little blood, so I went to sick call, they told me

to cut the dose in half…nothing to worry about…others in the unit had similar

vision problems… “

» SSgt TS, Gulf War Veteran (GRAC Report, 2008)

48


Chemical Warfare - Nerve Agents

• Acetylcholinesterases (AChE) similar to organophosphate pesticides

• Readily absorbed by inhalation, ingestion and dermal contact

• Rapidly fatal systemic effects may occur

• Most toxic chemical warfare agents

– G-Type Nerve Agents

• Clear colorless liquids, volatile at ambient temp

• Tabun (GA); Sarin (GB); Soman (GD)

– V-Type Nerve Agents

• Amber liquid, low volatility unless high temp

• VX

M190 Honest John chemical warhead section containing demonstration M134 GB (Sarin) bomblets.

49


Symptoms of Nerve Agent Exposure

• Dose dependent

• Those potentially exposed typically recall certain symptoms

associated with low to moderate level exposures.

• Symptoms secondary to mild to moderate exposure typically

resolve within weeks after exposure

• Body of literature that suggests possible long term damage

to receptors

50


Protecting Troops from Nerve Agents

51

• Chemical agent detection, alarm monitoring systems

– Detect nerve agents at levels high enough to cause symptoms

– False alarm triggers - smoke, engine exhaust, rocket/missile propellant smokes, and

electromagnetic pulse (EMP).

– Repeated false alarms →ignoring and/or disabling the systems • Personal protective equipment (MOPP)

• Nerve agent prophylaxis (PB)

• Post-exposure treatment (antidotes)

Mission Oriented Protective Posture (MOPP) Personal Protection Gear

52

Level MOPP Personal Protection Gear

0 Protective mask in carrier, at

side.

1 Chemical agent detectors worn,

over garments worn, mask in

carrier at side.

2 Over garments and over boots

worn. Gloves and mask readily

accessible.

3 Mask, over garments, and over

boots worn. Gloves kept ready.

4 All protection worn.



Nerve Agent Pyridostigmine Pretreatment (NAPP) Pills

• Active agent - Pyridostigmine bromide (“PB”)

• Distributed in 1st GW as part of 3-drug regimen to protect troops from nerve

agent poisoning

– PB - “small white pills” intended for use before nerve gas attack.

– If exposed to nerve agents, self-inject with antidotes pre-packed auto-injectors (post-exposure treatment).

• Atropine

• 2-pralidoxime chloride (2-PAM)

53


Pyridostigmine Bromide (PB) Mechanism of Action

• PB is a carbamate compound, temporarily and reversibly binds

acetylcholinesterase (AChE)

– PB pre-treatment established blood levels adequate to temporarily bind about 30% of

circulating AChE

• Protect cholinergic receptors from excess AChE build up and “rescue” AChE in order to re-

stabilize cholinergic nerve transmission after nerve agent attack

• Orders for initiating PB pretreatment issued by unit commanders

• NAPP blister packs had 21 pills

– 30 mg q8h X 7d

54


PB and GW-related Symptoms

• ACh is key regulator of muscle action, pain, mood, memory and sleep → prominent symptoms in ill GW Vets

• PB may alter regulation of ACh

– There is large individual variation in enzyme inhibition for same PB dose (15 to 25 fold

differences)

– Widespread differences in the time course of clinical and/or toxic effects of PB

• Animal studies demonstrate some long lasting/permanent effects after stopping PB

– PB toxicity may be enhanced by stress, heat, and exposures to pesticides and/or nerve

agents

• Use of PB in 1st GW associated with higher rates of side effects than commonly observed in

clinical settings

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Was I Exposed? GW Veteran-Reported Exposures to Neurotoxicants


US Gulf

War Vets

US Army US Navy

Seabees

UK Gulf

War Vets

Took PB Pills 49% 66% 33% 82%

Used personal pesticides 48% 46% 35% 69%

Exposed to nerve

gas/chemical agent

10% 19% 3% 9%

56

• Nearly 2 out of 3 Gulf War Vets in the U.S. national survey reported they had heard

chemical alarm sounds or put on their MOPP gear

– Only 10% believed they were exposed to nerve or chemical agents in theater (GRAC report, 2008)

57

“We cannot rule out pyridostigmine

bromide as a possible contributor to

the increased health symptoms in

some Gulf War Veterans.”

-Golomb & Anthony RAND National Defense Research Institute

http://www.rand.org/pubs/testimonies/2005/CT164.pdf

http://www.rand.org/pubs/testimonies/2005/CT164.pdf


Exposure-Disease Association vs. Causation

Exposure Assessment: Individually focused • Consider:

– Childhood

– Potential sources of environmental exposures

– Place of residence

– Parents’ occupations

– Part-time jobs/pre-military jobs

– Hobbies

– Travel

• Potential contributors to current health issues

– Childhood illnesses

– Allergies/Asthma

– Cigarette smoking in household

– Chronic diseases

– Injuries

• MILITARY EXPOSURES • Post military exposures

Causal Analysis: Population-based

58

• Hill’s Criteria of Causation:

– Strength of association

– Consistency

– Specificity

– Temporality

– Biological gradient

– Plausibility

– Coherence

– Experimental evidence

– Analogy

• ASSOCIATION ≠ CAUSATION


Exposure Assessment in Context of the Veteran’s World

Physical Impairments Memory/Concentration

problems

Divorce Homelessness

Pain Non-

combat injury

Combat injury TBI Marital/Family

financial stressors

Family

dysfunction

Poor

general

health

Non-combat illness

Spiritual

struggles

Residuals

of toxin

exposure

Environmental exposure illness

Spiritual/ Existential concerns

Post-combat symptoms

Unexplained

symptoms

Hearing loss

tinnitus

Job loss

PTSD, depression,

suicide

Mental Health

Needs, benefits,

C&P Financial

problems Substance

abuse Sleep problems

Mood changes

59


Addressing the (Frustrated) Veteran Goal: Impact Quality of Life

Veteran • Hostility

• Frustration

• Fear

• Unhappiness

• Pessimism

• Mistrust

• Misinformation

Clinician

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• Empathy

• More Empathy - Let them talk

• Impact Expectations

• Hope

• Optimism

• Truth

• Educate

• Serenity Prayer Attitude

Why Should We Care About Veterans’ Exposure Concerns?

Because they cared for us.

SO WHY SHOULD WE CARE ABOUT

VETERANS’ EXPOSURE CONCERNS?

61 VETERANS HEALTH ADMINISTRATION

Documents

Conducting an Exposure Assessment Evaluation Issues